40,000 Serious Incidents recorded by NHS trusts

Posted on 21st February 2018

More than 40,000 Serious Incidents have been recorded by NHS trusts and public health boards in England and Wales in just a two year period from 1st April 2015 – 31st March 2017 according to new research by medical negligence solicitors, Blackwater Law, which is thought to be the first of its kind to look at the issue in such depth.

More than 40,000 Serious Incidents have been recorded by NHS trusts and public health boards in England and Wales in just a two year period from 1st April 2015 – 31st March 2017 according to new research by medical negligence solicitors, Blackwater Law, which is thought to be the first of its kind to look at the issue in such depth.

Although no standard definition of a Serious Incidents exists, they are considered to be adverse events whereby the consequences to patients and NHS organisations are so significant that a heightened level of response and investigation is justified. Events that constitute a Serious Incident include unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm, as well as incidents affecting an NHS Trust’s ability to provide services.

Freedom of Information requests made by Blackwater Law show that from 1st April 2016-31st March 2017 a total of 20,433 Serious Incidents were recorded by 228 NHS trusts and 7 Welsh health boards in England and Wales, compared to 20,235 the previous year[i].

Commenting on the research, Jason Brady, Partner & Head of Blackwater Law, stated:

“It is truly concerning to learn that the number of Serious Incidents being recorded by NHS trusts across England and Wales stands at such a significant figure. It is crucial to remember that these are not just statistics. Each of these incidents is a patient and a family that may be suffering, potentially unnecessarily, with possible long-term implications for their future and quality of life.”

The research categorised NHS trusts according to their primary services into either acute and community health, mental health or ambulance trusts in order to further understand the most commonly recorded types of Serious Incident within each trust type:

171 acute and community health trusts

53 mental health trusts

11 ambulance trusts

Of the 235 NHS trusts and Welsh health boards in England and Wales whose data is included in the report, 132 – or 56% – provided a breakdown of the type of Serious Incidents. These amounted to 960 different categorisations and descriptions which were grouped into similar, commonly recorded Serious Incidents.

Acute and community health trusts (physical health)

A total of 27,789 Serious Incidents have been recorded from 1st April 2015 to 31st March 2017

24% of the 171 acute and community health trusts and public health boards recorded 100 or more Serious Incidents in 2016/2017. 7% recorded 10 or fewer Serious Incidents during the same period

The Pennine Acute Hospitals NHS Trust recorded the most number of Serious Incidents, with 778 recorded in 2016/2017[ii], followed by Betsi Cadwaladr University Health Board with 668 and Portsmouth Hospitals NHS Trust with 389

Of the trusts that provided a breakdown of the types of Serious Incidents, the most frequently recorded, accounting for almost a quarter (22.4%), was pressure damage, sores or ulcers. Sores and ulcers are often avoidable, but where severe enough to be recorded as a Serious Incident can cause significant pain and suffering. In the worst cases they can lead to life-threatening conditions such as blood poisoning and gangrene.

Ambulance trusts

Ambulance trusts across England and Wales recorded a total of 1,007 Serious Incidents over the two year period

The number of Serious Incidents recorded grew by almost a tenth (9.3%) between April 2015-March 2016 and April 2016-March 2017

Of the trusts that provided a breakdown of the types of Serious Incidents, the majority of the Serious Incidents (54%) related to delays in response and provision of treatment and issues regarding the quality of clinical and patient care provided by paramedics

Mental health trusts

The 53 Mental health trusts in England recorded 11,872 Serious Incidents since 1st April 2015 through to 31st March 2017

Almost half (47%) of the mental health trusts recorded 100 or more Serious Incidents in the most recent full financial year

According to data provided by more than half of the mental health trusts contacted regarding the type of Serious Incidents being recorded, almost a quarter (24.2%) related to unexplained or unexpected death of patients and a further 23.2% related to suicide and self-harm, including cases of attempted and suspected suicide and self-harm

Mr Brady of Blackwater Law said of the findings relating to NHS mental health trusts:

“It was very worrying indeed to learn not only of the significant number of Serious Incidents being recorded by mental health trusts across the country, but also the severity of those types of Serious Incident most commonly recorded. These findings should further fuel the debate surrounding the quality of mental health services being provided, particularly in cases concerning the most vulnerable, high-risk patients.”

Other findings of the report include:

The Christie NHS Foundation Trust recorded the least number of Serious Incidents, with 1 recorded in 2016/2017[iii], followed by Liverpool Heart & Chest NHS Foundation Trust with 3[iv] and Public Health Wales also with 3

Following pressure damage, sores or ulcers, the most commonly recorded Serious Incidents in 2016-2017 at the 96 acute and community health trusts and Welsh health boards that provided a breakdown were:

Following unexplained or unexpected death of patients and incidents of suicide and self-harm, including cases of attempted and suspected suicide and self-harm, the most commonly recorded Serious Incidents in 2016-2017 at the 29 mental health trusts that provided a breakdown were:

Other than delays in response and provision of treatment and issues regarding the quality of clinical and patient care provided by paramedics, the most commonly recorded Serious Incidents in 2016-2017 at the 7 ambulance trusts that provided a breakdown were:

The Research:

A Freedom of Information (FOI) (2000) request was sent to all 242 NHS trusts and Welsh health boards in England and Wales that existed during the period considered. The request asked for the number of Serious Incidents recorded by the individual NHS trust for both of the financial years 2015/2016 and 2016/2017 as well as a breakdown of incident type, where this could be provided.

Five trusts provided data but explicitly refused permission for their organisations Serious Incident data to be used within this report and therefore have been omitted from the report in its entirety (Kettering General Hospital NHS Foundation Trust, University Hospital Birmingham NHS Foundation Trust, The Dudley Group NHS Foundation Trust, United Lincolnshire NHS Trust and West Hertfordshire NHS Trust). In addition, the report features no data relating to the two NHS trusts which did not respond to the original FOI request sent to them, or subsequent re-approaches (London North West University Healthcare NHS Trust and Norfolk & Norwich University Hospitals NHS Foundation Trust). As a result, this report features the data for Serious Incidents recorded by 228 NHS trusts in England and Wales and seven Welsh health boards.

Of the 235 NHS trusts and Welsh health boards in England and Wales whose data is included in the report, 132 provided a breakdown of the type of Serious Incidents. These amounted to 960 different categorisations and descriptions which were grouped into similar, commonly occurring Serious Incidents.

Data has been provided by NHS trusts and Welsh health boards directly via email or via the Trust or Welsh Health Board providing direction to an official Trust or Health Board document, in response to an FOI request. Where provided by direction to a document, endnotes referenced against the Trust or Health Board identify this document.

Every effort has been taken to ensure the data is accurate; however Blackwater Law has relied on the accuracy of the data as provided by individual NHS trusts and health boards.

This press release and the accompanying report contain public sector information licensed to Blackwater Law under the Open Government Licence v3.0.[v] , the Open Government Licence v2.0.[vi] and the Re-use of Public Sector Information Regulations (2015)[vii].

About Blackwater Law:

Blackwater Law is a team of specialist medical negligence and serious personal injury solicitors.

[i] Data was unavailable for six NHS trusts for the financial year 2015/2016 and therefore has not been included within the total for this year. Data for these trusts was available for the year 2016/2017 and therefore has been included in the total for the year 2016/2017.

[ii] Noted at request of Trust: It is worth noting that the trust recorded 643 “A&E Extended Wait For Assess (More Than 12 Hrs)” as Serious Incidents in 2016/17 which were no harm events, but the CCG requested we logged them as Serious Incidents. The Pennine Acute Hospitals NHS Trust did not provide Blackwater Law with a breakdown of all Serious Incidents providing for categorisation.

[iv] Noted at request of Trust: However it is worth noting that the trust recorded 643 “A&E Extended Wait For Assess (More Than 12 Hrs)” as Serious Incidents in 2016/17 which were no harm events, but the CCG requested we logged them as Serious Incidents. The Pennine Acute Hospitals NHS Trust did not provide Blackwater Law with a breakdown of all Serious Incidents providing for categorisation.

[v] Open Government Licence v3.0. for public sector information (delivered by The National Archives). Accessible online via: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/

[vi] Open Government Licence v2.0. for public sector information (delivered by The National Archives), accessible online via: http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/